Brookdale Desert Ridge

Based on interview and documentation review, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a personnel member chemically restrained a resident. Findings include: 1. In an interview, E1 reported an incident between E3 and R4 involving E3 chemically restraining R4. 2. A review of facility documentation revealed an incident report detailing the aforementioned incident which occurred on December 18, 2025. The report stated: “12/18/2025 at 11:20am, [E4] reported that [R4] said to [E4] last night [R4] was given a medication but was told it was a vitamin by [E3]. [R4] said that it was a lorazepam because of how it makes [R4] feel afterwards. 12/18/2025 at 12:08pm, via phone spoke with [E3]. [E2] asked [E3] if [E3] gave the medication the resident and [E3] said yes, and when asked why, [E3] said [R4] needed it, saying that [R4] kept pushing [R4’s] pendant for things unrelated to care. [E3] was asked if resident refused the medication and [E3] said no, [R4] questioned what it was and I told [R4] it was a vitamin so that [R4] would take it.” 3. In an interview, E1 reported E3’s actions were unacceptable. E1 reported E1 suspended E3’s employment pending investigation. E1 reported E3 resigned shortly thereafter and has not returned to the facility. This is an uncorrected citation from the complaint inspection conducted on December 15, 2025, and the complaint and compliance inspection conducted on July 7, 2025, and a repeat citation from the complaint and compliance inspection conducted on July 29 and 31, 2024.

Based on interview and documentation review, the manager failed to ensure a resident was not subjected to restraint, for one of four sampled residents. The deficient practice posed a risk as a personnel member chemically restrained a resident. Findings include: 1. In an interview, E1 reported an incident between E3 and R4 involving E3 chemically restraining R4. 2. A review of facility documentation revealed an incident report detailing the aforementioned incident which occurred on December 18, 2025. The report stated: “12/18/2025 at 11:20am, [E4] reported that [R4] said to [E4] last night [R4] was given a medication but was told it was a vitamin by [E3]. [R4] said that it was a lorazepam because of how it makes [R4] feel afterwards. 12/18/2025 at 12:08pm, via phone spoke with [E3]. [E2] asked [E3] if [E3] gave the medication the resident and [E3] said yes, and when asked why, [E3] said [R4] needed it, saying that [R4] kept pushing [R4’s] pendant for things unrelated to care. [E3] was asked if resident refused the medication and [E3] said no, [R4] questioned what it was and I told [R4] it was a vitamin so that [R4] would take it.” 3. In an interview, when the Compliance Officer informed E1 using a medication in such a manner is considered chemical restraint, E1 agreed, stating, “Right.” E1 reported E3’s actions were unacceptable. E1 reported E1 suspended E3’s employment pending investigation. E1 reported E3 resigned shortly thereafter and has not returned to the facility.

Based on documentation review, record review, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for three of four sampled residents. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication and as the Department was provided false or misleading information. Findings include: 1. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint inspection conducted on July 30, 2025. The POC indicated this deficiency was corrected on October 24, 2025. The POC stated, “All residents are receiving their medications as ordered by 10/24/2025.” 2. A review of R1's medical record revealed R1’s date of occupancy was before October 24, 2025 (the date on the POC). The review revealed a current service plan which indicated R1 received medication administration. The review further revealed a series of medication administration records (MARs) dated December 2025 and January 2026. The MARs indicated facility personnel administered allopurinol, aspirin, famotidine, levothyroxine, metoprolol, and simvastatin to R1 in December 2025 and January 2026. However, the review revealed no signed medication orders for the six medications. 3. In an interview, E2 reported E2 was unable to find R1’s orders for the six aforementioned medications. 4. A review of R2's medical record revealed a current service plan which indicated R2 received medication administration. The review revealed a series of MARs dated December 2025 and January 2026. The MARs indicated facility personnel administered aspirin to R2 in December 2025 and aspirin and quetiapine to R2 in January 2026. However, the review revealed no signed medication orders for the two medications. 5. A review of R4's medical record revealed R4’s date of occupancy was before October 24, 2025 (the date on the POC). The review revealed a current service plan which indicated R4 received medication administration. The review further revealed a MAR dated December 2025 which indicated facility personnel administered aspirin, levothyroxine, and lorazepam to R4. However, the review revealed no signed medication orders for the three medications. This is a repeat citation from the complaint inspection conducted on July 30, 2025.

Based on interview and documentation review, the manager failed to ensure a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies. Findings include: 1. In an interview, E1 reported an incident between R3 and E3, stating, “We had an associate remove a resident’s pendant.” E1 reported E3 removed the pendant from R3’s room and did not return it until the end of E3’s overnight shift several hours later. 2. A review of facility documentation revealed an incident report detailing an incident between R3 and E3 on October 26, 2025. The report stated: “On 10/27/2025 [at] approximately 10:52am, [E4] reported to [E2] that [R3] said that [E3] took [R3’s] pendant away from [R3], threw it and that [R3] did not have it from 1 am until [R3] woke up at 8 am.” The report further stated, “[E3] was suspended pending investigation via phone as soon as was possible following report.” 3. In an interview, E1 reported E3 taking R3’s pendant was unacceptable and E1 terminated E3 shortly after E1 was made aware of the situation. This is an uncorrected citation from the complaint and compliance inspection conducted on July 7, 2025, and a repeat citation from the complaint and compliance inspection conducted on July 29 and 31, 2024.

Based on record review, interview, documentation review, and observation, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies was available and accessible in a bedroom being used by a resident receiving personal care services. The deficient practice posed a risk if personnel could not react to a resident's needs or emergencies. Findings include: 1. A review of R3’s medical record revealed a service plan which indicated R3 received personal care services. 2. In an interview, E1 reported an incident between R3 and E3, stating, “We had an associate remove a resident’s pendant.” E1 reported E3 removed the pendant from R3’s room and did not return it until the end of E3’s overnight shift several hours later. 3. A review of facility documentation revealed an incident report detailing an incident between R3 and E3 on October 26, 2025. The report stated: “On 10/27/2025 [at] approximately 10:52am, [E4] reported to [E2] that [R3] said that [E3] took [R3’s] pendant away from [R3], threw it and that [R3] did not have it from 1 am until [R3] woke up at 8 am.” The report further stated, “[E3] was suspended pending investigation via phone as soon as was possible following report.” 4. In an interview, E1 reported E3 taking R3’s pendant was unacceptable and E1 terminated E3 shortly after E1 was made aware of the situation. 5. The Compliance Officer observed R3’s pendant in R3’s bedroom within R3’s reach. However, the Compliance Officer observed no bell, intercom, or other mechanical means to alert employees to R3’s needs or emergencies that would have been available and accessible in R3’s bedroom when R3 did not have R3’s pendant.

Based on interview and documentation review, the manager failed to provide written notification to the Department of a resident’s self-injury, within two working days after the resident inflicted a self-injury that requires immediate intervention by an emergency services provider, for one of three sampled residents. Findings include: 1. In an interview, E1 reported R3 had an accident, emergency, or injury that resulted in R3 needing medical services on July 14, 2025. 2. A review of facility documentation revealed an “INCIDENT INVESTIGATION” report dated July 14-15, 2025. The report stated: “[E3] enters [R3’s] room and resident appeared to be sleeping and snoring. [E3] approaches and attempts to wake [R3] for [R3’s] afternoon meds and [R3] does not wake. [E3] attempts several times shaking [R3’s] shoulder and rubbing [R3’s] leg without response. [E3] calls for assistance and hospice nurse [O1] enters room and [E3 and O1] continue to try to rouse [R3] and upon rolling [R3] to [R3’s] back [E3 and O1] find pills stuck to [R3’s] face, lips and the inside of [R3’s] mouth. At this time [E3 and O1] are unable to get a response and call 911…07/15/2025 - Approximately 1000am - Spoke to [individual] at Suncrest Hospice - [R3] is recovered and back to baseline.” 3. In an interview, E1 reported E1 originally thought the incident constituted self injury. However, E1 confirmed E1 reported the self injury to Adult Protective Services and not to the Department. E1 reported R1’s family later commented about the incident, not believing it was a case of self injury. E1 reported the hospital found no traces of opioids or of an overdose.

Based on record review, interview, and observation, the manager failed to ensure a resident's medical record contained documentation of medication administered to the resident that included the date and time of administration or assistance, the dosage, and the name and signature of the individual administering the medication, for one of three sampled residents. The deficient practice posed a risk as the Department was provided false or misleading information. Findings include: 1. A review of R1’s medical record revealed an unsigned medication order for “MIRTAZAPINE 15 ORAL TABLET 0.5 tab PO QHS x 8 days then increase to 1 tab PO QHS 30 day(s)” dated July 8, 2025. The review revealed a medication administration record (MAR) dated July 2025. The MAR revealed the following: - On July 9-13, 2025, facility personnel administered R1 one half-tablet of mirtazapine 15 mg (7.5 mg); - On July 14-16, 2025, facility personnel did not administer R1 one half-tablet of mirtazapine 15 mg (7.5 mg), with notes to “See Med Note;” - On July 17, 2025, facility personnel did not administer R1 one tablet of mirtazapine 15 mg, with notes to “See Med Note;” - On July 18, 2025, facility personnel administered R1 one tablet of mirtazapine 15 mg; - On July 19-20, 2025, facility personnel did not administer R1 one tablet of mirtazapine 15 mg; and - On July 21-29, 2025, facility personnel administered R1 one tablet of mirtazapine 15 mg. The MAR revealed documentation demonstrating facility personnel administered a total of five half-tablets and 10 full tablets. The review further revealed an “Alert Charting Note” dated July 17, 2025, at 9:40 PM created by E2. The note stated: “Called [R1’s family member] about non payment of pharmacy bill. Confirmed that [R1’s family member] will get in touch with [R1’s other family member] to settle the matter. [R1’s family member] promised to settle the matter by the close of the business. 2. In an interview, E1 reported the pharmacy did not deliver the medication on time because the pharmacy bill had not been paid at the time. E1 reported E1 did not know exactly when the medication was delivered. 3. The Compliance Officer observed R1’s pharmacy-provided multi-dose package of mirtazapine. The package revealed the medication was delivered on July 22, 2025, and only eight tablets had been administered, in contrast with the 15 and a half tablets documented as administered on the MAR. 4. In a telephonic interview, E2 reported the mirtazapine had not been delivered for several days after July 8, 2025. E2 reported the medication was not administered on those dates, though E2 reported not remembering the exact dates. E2 stated the medication was “not given” on July 18, 2025, even though it was documented by E2 as administered. E2 reported having not administered half-tablets of the medication to R1. E2 confirmed E2 administered only full tablets of the medication to R1. E2 stated the issues with the administration and documentation constituted a “

Based on record review and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1’s medical record revealed a current service plan which indicated R1 received medication administration. The review revealed a medication administration record (MAR) dated July 2025. The MAR revealed facility personnel administered mirtazapine to R1 on July 9-13, 18, and 21-29, 2025. However, the review revealed no signed medication order for the mirtazapine. 2. In an interview, E1 confirmed caregivers administered R1’s mirtazapine. 3. In a telephonic interview, E2 confirmed E2 administered R1’s mirtazapine during E2’s shifts on July 9-13 and 21-29, 2025. 4. A review of R3’s medical record revealed a current service plan which indicated R3 received medication administration. The review revealed a MAR dated July 2025. The MAR revealed facility personnel administered multiple medications on a daily basis to R3 on July 1-14, 2025. However, the review revealed no signed medication orders.

Based on interview and documentation review, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's primary care provider (PCP) when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. The deficient practice posed a potential risk of re-injury if a resident did not receive adequate follow-up care. Findings include: 1. In an interview, E1 reported R3 had an accident, emergency, or injury that resulted in R3 needing medical services on July 14, 2025. 2. A review of facility documentation revealed an “INCIDENT INVESTIGATION” report dated July 14-15, 2025. The report revealed R3 had an accident, emergency, or injury that resulted in R3 needing medical services. The report revealed no documentation demonstrating whether facility personnel contacted R3’s PCP. 3. In an interview, when the Compliance Officer asked if R3’s PCP was hospice, E1 reported it was not. E1 confirmed R3 had a PCP separate from hospice. E1 reported facility personnel contacted R3’ hospice when the incident occurred and not R3’s PCP. When the Compliance Officer asked if E1 had documentation of notification of R3’s PCP immediately following the incident, E1 stated, “We don’t.” This is a repeat citation from the complaint and compliance inspections completed on July 31, 2024, and August 24, 2023.

Based on record review and interviews, the manager failed to ensure that a caregiver or an assistant caregiver provided a resident with the assisted living services in the resident's service plan for one of two residents reviewed. The deficient practice posed a risk as service plan to directed services was not followed. Findings include: 1. A review of R8's service plan revealed a service plan for Personal Care services that included incontinence care with changing every two hours or as needed. 2. A review of a progress note dated March 9, 2025, revealed that R8 requested incontinence care assistance from E8 around 1am. E8's progress note stated "resident wanted to be changed but was not that wet, resident told to wait two hours for scheduled change." The resident requested for assistance a second time around 3:30 am and was assisted by E8. 3. A review of the facility's Policies and Procedures titled, "Scope of Services', stated, "Personal Care services includes assistance with activities of daily living that can be performed by persons without professional skills or professional training. Additionally, it includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a licensed nurse or as otherwise provided by law." 4. During the exit interview, E1 acknowledged that a caregiver or an assistant caregiver failed to provide a resident with the assisted living services in the resident's service plan.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk of injury and violated a resident's rights. Findings include: 1. A review of R8's service plan revealed that the resident received Personal Care services, which included incontinence care. 2. A review of a progress note dated March 9, 2025, revealed that R8 requested incontinence care assistance from E8 around 1am. E8's progress note stated "resident wanted to be changed but was not that wet, resident told to wait two hours for scheduled change." The resident requested for assistance a second time around 3:30 am and was assisted by E8. 3. A review of E8's personnel record revealed that the employee was put on suspension pending an internal investigation on March 16, 2025. The employee was terminated for violation of facility policy on April1, 2025. 4. A review of the facility's Policies and Procedures titled, "Resident Rights" stated, "Residents will be treated with dignity, respect, and consideration." 5. In an interview, E1 revealed that when the manager learned of the behavior that E8 exhibited towards R8, the employee was suspended pending an investigation. The employee was terminated for violating policy. 6. In an interview, E1 acknowledged that the manager failed to ensure that a resident was treated with dignity, respect, or consideration.

Based on documentation review, record review, and interview, the manager failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided to the resident, for two of two residents sampled. The deficient practice posed a risk as the service plans did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Night Check Policy," last revised: November 2018. The policy stated "Policy Overview - Resident care staff should make night checks of the residents. A resident or his/her legally responsible party may choose not to have the associates perform night checks. The choice not to receive night checks should be documented in a Negotiated Risk Agreement, where permitted by state regulation, and on the resident's Service Plan. Policy Detail: 1. Associates should perform night checks approximately every four (4) to six (6) hours or as determined by the residents' need…” 2. A review of R1's Activities of Daily Living (ADL) sheets indicated night checks were provided by the caregivers on January, February and March 2025. 3. A review of R2’s Activities of Daily Living (ADL) sheets indicated night checks were provided by the caregivers on January and February 2025. 4. A review of R1's and R2's medical records revealed current service plans. However, the service plans did not include the frequency of night checks or the choice not to have night checks. Additionally, the medical records did not include a documented Negotiated Risk Agreement as specified in the policy. 5. A review of R2's medical record revealed a current service plan dated December 25, 2024. The service plan stated, "[R2] requires staff assist with all transfers…[R2] is non-weight bearing and requires care staff to use Geri chair for ambulation through the facility. [R2] is a 2 person assist with the use of a mechanical lift for transfers." However, there was no documentation of the need for repositioning the resident. 6. In an interview, E2 reported the staff repositioned R2 every two hours with incontinence care. 7. In an interview, E1 and E2 acknowledged R1’s and R2's written service plans did not include the amount, type, and frequency of the above mentioned services provided to the residents.